Provider Demographics
NPI:1073047460
Name:IMUS SLEEP PLLC
Entity Type:Organization
Organization Name:IMUS SLEEP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:IMUS
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:480-570-9766
Mailing Address - Street 1:PO BOX 20610
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85277-0610
Mailing Address - Country:US
Mailing Address - Phone:480-296-7642
Mailing Address - Fax:480-296-7643
Practice Address - Street 1:4022 E PRESIDIO ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215-1113
Practice Address - Country:US
Practice Address - Phone:480-296-7642
Practice Address - Fax:480-296-7643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZCRNA0698367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty